Intraoperative Ventilation of Morbidly Obese Patients Guided by Transpulmonary Pressure

  • Lars Eichler
  • Katarzyna Truskowska
  • A. Dupree
  • P. Busch
  • Alwin E. Goetz
  • Christian Zöllner
Original Contributions
  • 279 Downloads

Abstract

Background

Bariatric surgery has proven a successful approach in the treatment of morbid obesity and its concomitant diseases such as diabetes mellitus and arterial hypertension. Aiming for optimal management of this challenging patient cohort, tailored concepts directly guided by individual patient physiology may outperform standardized care. Implying esophageal pressure measurement and electrical impedance tomography—increasingly applied monitoring approaches to individually adjust mechanical ventilation in challenging circumstances like acute respiratory distress syndrome (ARDS) and intraabdominal hypertension—we compared our institutions standard ventilator regimen with an individually adjusted positive end expiratory pressure (PEEP) level aiming for a positive transpulmonary pressure (PL) throughout the respiratory cycle.

Methods

After obtaining written informed consent, 37 patients scheduled for elective bariatric surgery were studied during mechanical ventilation in reverse Trendelenburg position. Before and after installation of capnoperitoneum, PEEP levels were gradually raised from a standard value of 10 cm H2O until a PL of 0 +/− 1 cm H2O was reached. Changes in ventilation were monitored by electrical impedance tomography (EIT) and arterial blood gases (ABGs) were obtained at the end of surgery and 5 and 60 min after extubation, respectively.

Results

To achieve the goal of a transpulmonary pressure (PL) of 0 cm H2O at end expiration, PEEP levels of 16.7 cm H2O (95% KI 15.6–18.1) before and 23.8 cm H2O (95% KI 19.6–40.4) during capnoperitoneum were necessary. EIT measurements confirmed an optimal PEEP level between 10 and 15 cm H2O before and 20 and 25 cm H2O during capnoperitoneum, respectively. Intra- and postoperative oxygenation did not change significantly.

Conclusion

Patients during laparoscopic bariatric surgery require high levels of PEEP to maintain a positive transpulmonary pressure throughout the respiratory cycle. EIT monitoring allows for non-invasive monitoring of increasing PEEP demand during capnoperitoneum. Individually adjusted PEEP levels did not result in improved postoperative oxygenation.

Keywords

PEEP Transpulmonary pressure Bariatric surgery Anesthesia Morbid obesity 

Notes

Compliance with Ethical Standards

Conflict of Interest

Lars Eichler, Katarzyna Truskowska, Alwin E. Goetz, and Christian Zöllner report support by Carefusion, Höchberg, Germany, who provided the respirator (Avea™) and esophageal pressure probes and Dräger, Lübeck, Germany, who provided the EIT monitor (Pulmovista 500™).

Anna Dupree and Philipp Busch report no conflict of interest.

References

  1. 1.
    Arterburn DE, Maciejewski ML, Tsevat J. Impact of morbid obesity on medical expenditures in adults. Int J Obes. 2005;29:334–9.CrossRefGoogle Scholar
  2. 2.
    Grieve E, Fenwick E, Yang HC, et al. The disproportionate economic burden associated with severe and complicated obesity: a systematic review. Obes Rev. 2013;14:883–94.CrossRefPubMedGoogle Scholar
  3. 3.
    Puzziferri N, Roshek 3rd TB, Mayo HG, et al. Long-term follow-up after bariatric surgery: a systematic review. JAMA. 2014;312:934–42.CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Dixon JB, Schachter LM, O'Brien PE, et al. Surgical vs conventional therapy for weight loss treatment of obstructive sleep apnea: a randomized controlled trial. JAMA. 308:1142–9.Google Scholar
  5. 5.
    Reoch J, Mottillo S, Shimony A, et al. Safety of laparoscopic vs open bariatric surgery: a systematic review and meta-analysis. Arch Surg. 2011;146:1314–22.CrossRefPubMedGoogle Scholar
  6. 6.
    Pelosi P, Croci M, Ravagnan I, et al. Total respiratory system, lung, and chest wall mechanics in sedated-paralyzed postoperative morbidly obese patients. Chest. 1996;109:144–51.CrossRefPubMedGoogle Scholar
  7. 7.
    Behazin N, Jones SB, Cohen RI, et al. Respiratory restriction and elevated pleural and esophageal pressures in morbid obesity. J Appl Physiol. 1985;108:212–8.CrossRefGoogle Scholar
  8. 8.
    El-Dawlatly AA, Al-Dohayan A, Abdel-Meguid ME, et al. The effects of pneumoperitoneum on respiratory mechanics during general anesthesia for bariatric surgery. Obes Surg. 2004;14:212–5.CrossRefPubMedGoogle Scholar
  9. 9.
    Dumont L, Mattys M, Mardirosoff C, et al. Changes in pulmonary mechanics during laparoscopic gastroplasty in morbidly obese patients. Acta Anaesthesiol Scand. 1997;41:408–13.CrossRefPubMedGoogle Scholar
  10. 10.
    Futier E, Constantin JM, Pelosi P, et al. Noninvasive ventilation and alveolar recruitment maneuver improve respiratory function during and after intubation of morbidly obese patients: a randomized controlled study. Anesthesiology. 114:1354–63.Google Scholar
  11. 11.
    Perilli V, Sollazzi L, Modesti C, et al. Comparison of positive end-expiratory pressure with reverse Trendelenburg position in morbidly obese patients undergoing bariatric surgery: effects on hemodynamics and pulmonary gas exchange. Obes Surg. 2003;13:605–9.CrossRefPubMedGoogle Scholar
  12. 12.
    Futier E, Constantin JM, Petit A, et al. Positive end-expiratory pressure improves end-expiratory lung volume but not oxygenation after induction of anaesthesia. Eur J Anaesthesiol. 2010;27:508–13.PubMedGoogle Scholar
  13. 13.
    Futier E, Constantin JM, Pelosi P, et al. Intraoperative recruitment maneuver reverses detrimental pneumoperitoneum-induced respiratory effects in healthy weight and obese patients undergoing laparoscopy. Anesthesiology. 2010;113:1310–9.CrossRefPubMedGoogle Scholar
  14. 14.
    Neligan PJ, Malhotra G, Fraser M, et al. Noninvasive ventilation immediately after extubation improves lung function in morbidly obese patients with obstructive sleep apnea undergoing laparoscopic bariatric surgery. Anesth Analg. 2010;110:1360–5.CrossRefPubMedGoogle Scholar
  15. 15.
    Bardoczky GI, Yernault JC, Houben JJ, et al. Large tidal volume ventilation does not improve oxygenation in morbidly obese patients during anesthesia. Anesth Analg. 1995;81:385–8.PubMedGoogle Scholar
  16. 16.
    Sutherasan Y, D’Antini D, Pelosi P. Advances in ventilator-associated lung injury: prevention is the target. Expert Rev Respir Med. 8:233–48.Google Scholar
  17. 17.
    Futier E, Pereira B, Jaber S. Intraoperative low-tidal-volume ventilation. N Engl J Med. 369:1862–3.Google Scholar
  18. 18.
    Stahl DL, North CM, Lewis A, et al. Case scenario: power of positive end-expiratory pressure: use of esophageal manometry to illustrate pulmonary physiology in an obese patient. Anesthesiology. 2014;121:1320–6.CrossRefPubMedGoogle Scholar
  19. 19.
    Talmor D, Sarge T, Malhotra A, et al. Mechanical ventilation guided by esophageal pressure in acute lung injury. N Engl J Med. 2008;359:2095–104.CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    Grasso S, Terragni P, Birocco A, et al. ECMO criteria for influenza A (H1N1)-associated ARDS: role of transpulmonary pressure. Intensive Care Med. 2012;38:395–403.CrossRefPubMedGoogle Scholar
  21. 21.
    Pelosi P, Luecke T, Rocco PR. Chest wall mechanics and abdominal pressure during general anaesthesia in normal and obese individuals and in acute lung injury. Curr Opin Crit Care. 2011;17:72–9.CrossRefPubMedGoogle Scholar
  22. 22.
    Sindi A, Piraino T, Alhazzani W, et al. The correlation between esophageal and abdominal pressures in mechanically ventilated patients undergoing laparoscopic surgery. Respir Care. 2013;59:491–6.CrossRefPubMedGoogle Scholar
  23. 23.
    Cinnella G, Grasso S, Spadaro S, et al. Effects of recruitment maneuver and positive end-expiratory pressure on respiratory mechanics and transpulmonary pressure during laparoscopic surgery. Anesthesiology. 2012;118:114–22.CrossRefGoogle Scholar
  24. 24.
    Erlandsson K, Odenstedt H, Lundin S, et al. Positive end-expiratory pressure optimization using electric impedance tomography in morbidly obese patients during laparoscopic gastric bypass surgery. Acta Anaesthesiol Scand. 2006;50:833–9.CrossRefPubMedGoogle Scholar
  25. 25.
    Maracaja-Neto LF, Vercosa N, Roncally AC, et al. Beneficial effects of high positive end-expiratory pressure in lung respiratory mechanics during laparoscopic surgery. Acta Anaesthesiol Scand. 2009;53:210–7.CrossRefPubMedGoogle Scholar
  26. 26.
    Valenza F, Vagginelli F, Tiby A, et al. Effects of the beach chair position, positive end-expiratory pressure, and pneumoperitoneum on respiratory function in morbidly obese patients during anesthesia and paralysis. Anesthesiology. 2007;107:725–32.CrossRefPubMedGoogle Scholar
  27. 27.
    Talab HF, Zabani IA, Abdelrahman HS, et al. Intraoperative ventilatory strategies for prevention of pulmonary atelectasis in obese patients undergoing laparoscopic bariatric surgery. Anesth Analg. 2009;109:1511–6.CrossRefPubMedGoogle Scholar
  28. 28.
    Schumann R. Anaesthesia for bariatric surgery. Best Pract Res Clin Anaesthesiol. 2011;25:83–93.CrossRefPubMedGoogle Scholar
  29. 29.
    Reinius H, Jonsson L, Gustafsson S, et al. Prevention of atelectasis in morbidly obese patients during general anesthesia and paralysis: a computerized tomography study. Anesthesiology. 2009;111:979–87.CrossRefPubMedGoogle Scholar
  30. 30.
    Almarakbi WA, Fawzi HM, Alhashemi JA. Effects of four intraoperative ventilatory strategies on respiratory compliance and gas exchange during laparoscopic gastric banding in obese patients. Br J Anaesth. 2009;102:862–8.CrossRefPubMedGoogle Scholar
  31. 31.
    Futier E, Constantin JM, Paugam-Burtz C, et al. A trial of intraoperative low-tidal-volume ventilation in abdominal surgery. N Engl J Med. 369:428–37.Google Scholar
  32. 32.
    Grasso S, Stripoli T, De Michele M, et al. ARDSnet ventilatory protocol and alveolar hyperinflation: role of positive end-expiratory pressure. Am J Respir Crit Care Med. 2007;176:761–7.CrossRefPubMedGoogle Scholar
  33. 33.
    Rodriguez PO, Bonelli I, Setten M, et al. Transpulmonary pressure and gas exchange during decremental PEEP titration in pulmonary ARDS patients. Respir Care. 2012;58:754–63.Google Scholar
  34. 34.
    Chiumello D, Carlesso E, Cadringher P, et al. Lung stress and strain during mechanical ventilation for acute respiratory distress syndrome. Am J Respir Crit Care Med. 2008;178:346–55.CrossRefPubMedGoogle Scholar
  35. 35.
    Washko GR, O'Donnell CR, Loring SH. Volume-related and volume-independent effects of posture on esophageal and transpulmonary pressures in healthy subjects. J Appl Physiol. 2006;100:753–8.CrossRefPubMedGoogle Scholar
  36. 36.
    Pelosi P, Goldner M, McKibben A, et al. Recruitment and derecruitment during acute respiratory failure: an experimental study. Am J Respir Crit Care Med. 2001;164:122–30.CrossRefPubMedGoogle Scholar
  37. 37.
    Defresne AA, Hans GA, Goffin PJ, et al. Recruitment of lung volume during surgery neither affects the postoperative spirometry nor the risk of hypoxaemia after laparoscopic gastric bypass in morbidly obese patients: a randomized controlled study. Br J Anaesth. 2014;113(3):501–7.CrossRefPubMedGoogle Scholar
  38. 38.
    Lumb AB, Greenhill SJ, Simpson MP, et al. Lung recruitment and positive airway pressure before extubation does not improve oxygenation in the post-anaesthesia care unit: a randomized clinical trial. Br J Anaesth. 2010;104:643–7.CrossRefPubMedGoogle Scholar
  39. 39.
    Pok EH, Lee WJ. Gastrointestinal metabolic surgery for the treatment of type 2 diabetes mellitus. World J Gastroenterol. 2014;20:14315–28.CrossRefPubMedPubMedCentralGoogle Scholar
  40. 40.
    Adams ST, Salhab M, Hussain ZI, et al. Obesity-related hypertension and its remission following gastric bypass surgery—a review of the mechanisms and predictive factors. Blood Press. 2012;22:131–7.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2017

Authors and Affiliations

  1. 1.Department of Anesthesiology and Critical Care MedicineUniversity Medical Center Hamburg-EppendorfHamburgGermany
  2. 2.Department of General, Visceral, and Thoracic SurgeryUniversity Medical Center Hamburg-EppendorfHamburgGermany

Personalised recommendations